1. Living Kidney Transplant: The Influence of Intra-Operative Hemodynamics on Delayed Graft Function Ryan Schutt D.O.1,3, Jamie Case Ph.D.1, Bethany Barrick B.S.1, Alice Toll B.S.2, Randolph Schaffer M.D.1, Jonathan Fisher M.D.1, Christopher Marsh M.D.1 1Scripps Center for Organ and Cell Transplantation, Scripps Green Hospital, La Jolla, CA
2Research Department and Data Analytics, United Network for Organ Sharing, Richmond, VA
3Department of General Surgery, Naval Medical Center-San Diego, San Diego, CA
BACKGROUND
RESULTS
Living Kidney Transplant
n = 111
DGF
(dialysis in the first week)
n = 10 SF
(crt > 2.5 by end of first week)
n = 11 GF
n = 90
Despite advantages of living donor kidneys, intraoperative insults may subject these kidneys to poor outcomes. Therefore, we investigated whether intraoperative fluid volumes and hemodynamics in the donor, and recipient, could act as predictors of delayed graft function (DGF). Additionally, we investigated 1 year outcomes between groups.
OBJECTIVES
Determine the single center incidence of DGF in kidneys from living donors.
Determine the influence of post-perfusion recipient central venous pressure and hypotension (systolic <90mmHg or diastolic <50mmHg) on the incidence of DGF.
Determine the influence of donor pre-vascular isolation hypotension on the incidence of DGF.
Determine the influence of donor and recipient intra-operative fluid totals on the incidence of DGF.
Compare 1 year outcomes of graft function, biopsy findings and rejection between cohorts.
Table 1: Summary of Recipient Findings
Transplants (n = 111)
DGF (n = 10)
SF (n = 11)
GF (n = 90)
p-value
Recipient Variable
Age (years)
65.5 51
48.5
0.027
Sex
0.018
-Male
80% (8)
82% (9)
47% (42)
-Female
20% (2)
18% (2)
53% (48)
Hemodialysis
< 0.001
-No
10% (1)
73% (8)
69% (63)
-Yes
90% (9)
27% (3)
31% (28)
HLA Mismatch NS
33% (3)
9% (1)
13% (12)
67% (6)
91% (10)
87% (78)
Fluids Total (ml)
2250
2800
3000
Albumin
30% (3)
45% (5)
36% (31)
70% (7)
55% (6)
64% (55)
Intra-Operative Hypotension
40% (4)
56% (48)
60% (6)
44% (37)
Minimum CVP ≥ 12mmHg
56% (5)
24% (16)
0.009
Rejection
36% (4)
9% (8)
0.012
1 yr Kidney Function
0% (0)
1% (1)
100% (10)
100% (9)
98.6% (74)
Intra-Operative Hypotension (systolic < 90mmHg or diastolic < 50mmHg)
Table 2: Summary of Donor Findings
Donors (n = 111)
DGF (n=10)
SF (n = 11)
GF (n = 90)
p-value
Donor Variable
Age (years)
47.5 46 45 NS
Sex
-Male
60% (6)
55% (6)
45% (40)
-Female
40% (4)
45% (5)
55% (49)
Height (cm)
174
175.5
167
0.031
Weight (kg)
85.7
85.2
74.7
0.022
BSA (m2)
2.0
1.8
Fluids Total (ml)
2750
2800
Albumin
-No
100% (8)
96% (80)
-Yes
0% (0)
4% (3)
Intra-Operative Hypotension
56% (48)
44% (37)
Intra-Operative Hypotension (systolic < 90mmHg or diastolic < 50mmHg)
CONCLUSIONS
This single center retrospective review suggests that delayed graft function (i.e. DGF) in living kidney recipients is a rare event.
Poor graft function (i.e. DGF or SF) in the first week is associated with high intra-operative central venous pressure (≥12mmHg), despite no association with an incident of intra-operative hypotension. Furthermore, external factors such as larger donors may place the graft at risk for poor initial function. Operative fluid volumes showed no association with initial graft function.
DGF and SF were associated with rejection. Despite this, one year graft function and survival were comparable.
Prospective randomized studies are now needed to further elucidate the effects of intra-operative hemodynamics on initial graft function.
METHODS
Single institution retrospective chart review of all living kidney donors and recipients between the years
Donor and recipient demographics, intra-operative hemodynamic and fluid data, and outcomes were collected and analyzed.
First week graft function stratified recipients into three cohorts; DGF (need for dialysis), slow function (SF) (creatinine >2.5) and good function (GF).
Cohorts were analyzed for differences between intra-operative fluid totals, hemodynamics and 1 year outcomes.
Pearson Chi-square test for association was used for categorical variables, while the Kruskal-Wallis test was used for continuous variables.
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